Gut and Liver, Vol. 4, Suppl. 1, September 2010, pp. S44-49

original article

Percutaneous Radiologic Gastrostomy: A 12-Year Series

Franco Perona, Giorgio Castellazzi, Alessandro De Iuliis, and Laura Rizzo Alliance Medical Italy, Lissone, Italy

Background/Aims: Interventional radiologists have come the state of the art to achieve a feeding access in played a main role in the technical evolution of gas- patients with neoplastic involvement of the head and trostomy, from the first surgical/endoscopical ap- neck or oesophagus. However, PEG may fail in patients proaches to percutaneous interventional procedures. with stenotic lesions that cannot be passed by an This study evaluated the results obtained in a 12-year endoscope. Also, , gastric surgery, or other ana- series. Methods: During the period December 1996 tomical abnormalities making transillumination of the ab- to December 2008, 254 new consecutive gastro- dominal wall difficult, may lead to failure of PEG stomies and 275 replacement procedures were per- procedures.1 formed in selected patients. All of the cases were treated by a T-fastener gastropexy and tube place- As reported in the Literature surgical gastrostomy ment. The procedures were assessed by analyzing in- would be necessary in these cases. Interventional dications, patient selection, duration of the procedures, Radiology as become a valid and effective therapeutic al- and mortality. Results: All 254 first gastrostomies ternative to many pathologic conditions and percutaneous were successful; replacement procedures were also radiological gastrostomy (PRG) represents an alternative successfully performed. One (0.2%) patient with se- that avoids both surgery and endoscopy.1 vere neurologic disorders died after the procedure Despite encouraging results in literature, this method without signs of procedure-related complications, and has not yet gained widespread clinical acceptance. The of- seven (1.3%) major complications occurred (four duo- fer of this promising technique to clinicians of depart- denal lesions with peritoneal leakage, two gastric ments for radiation oncology, head and neck surgery, neu- bleedings, and one gastric lesion). Minor complications rology has been enthusiastically taken and they have read- were easily managed; three tube ruptures were ily accepted the modality. resolved. Conclusions: This long-term series and fol- low-up showed that a group of interventional radiol- The reasons of this approach are related to the need of ogist can effectively provide gastrostomy placement parenteral nutrition or enteric route for nutrition, to and long-term tube management. Percutaneous gas- avoid secondary . We have to take into ac- trostomy is less invasive than other approaches and it count that long-term nasogastric and parenteral devices satisfies the needs even of high-risk patients. (Gut are not feasible because of an increased risk of gas- Liver 2010;4(Suppl. 1):S44-49) tro-esophageal reflux and subsequent aspiration.2 Percutaneous gastrostomy represents a valid alternative, Key Words: Gastrostomy; Percutaneous endoscopic less invasive than surgical approach and more tolerated gastrostomy; T-fastener; Percutaneous radiological gas- from patients: it is an artificial entero-cutaneous fistula trostomy between stomach and the skin surface, and it can be ob- tained with endoscopic or radiologic method.3 INTRODUCTION In the last years, PEG has quickly replaced the surgical approach and it is the current standard procedure to ob- Percutaneous endoscopic gastrostomy (PEG) has be- tain a feeding access in these kind of patients.4

Correspondence to: Franco Perona Alliance Medical Italy, Piazza G. La Pira 9, Lissone (MI), Italy Tel: +39-039-46621, Fax: +39-039-4662201, E-mail: [email protected] DOI: 10.5009/gnl.2010.4.S1.S44 Perona F, et al: Percutaneous Radiologic Gastrostomy: A 12-Year Series S45

The reasons of failure of the endoscopic approach are spleen are marked by ultrasound. well known and allow the research of possible alter- The stomach was transorally probed with a 5 F catheter natives as percutaneous placement of feeding tubes like a and a guidewire, and then a nasogastric tube was placed valid option to surgery and endoscopy: the interventional shortly before the procedure to allow air insufflation: approach is easy and fast as well as less invasive as com- stomach was distended with variable volume of air from pared to surgery. 500 to 700 mL, using 60 mL syringe under fluoroscopic Few studies on PRG are focused on extensive series: control. Immediately before the catheter placement 5 mg so, the aim of this study is to analyze our experience in of Joshine N-butyl-bromide (Buscopan; Boehringer Ingel- PRG placement with gastropexy in large population focus- heim, Florence, Italy) was injected for in all ing on technical difficulties, patients selection and gastro- patients. After sterile cleaning of skin with Pyodine, in- stomy site management and complications. jection of Xylocane (2%) was obtained at the site of puncture.2 MATERIALS AND METHODS The area in which the gastrostomy tube will be in- serted is usually located in the left hypochondrium, 4-8 1. Patients cm from median line: a small skin incision is the first From January 1996 to December 2008, 529 patients step after local anaesthesia and then the stomach is punc- (229 women, 300 men; mean age, 65 years), referred to tured in mid-distal body, to avoid the gastric major arte- our Center, were considered eligible for PRG placement: rial branches, with 18-gauge needle. The regular place- 254 for first placement, and 275 for replacement. ment of the needle is detected by aspiration of air and The clinical indications for first procedure were neuro- flushing with contrast media; after checking the correct logical disease, head and neck cancers; we exclude from position of the needle the T-fastener anchor bar is loaded our study patients with total gastrectomy, gastric carcino- (Cope Gastrointestinal Suture Anchor; Cook, Blooming- matosis, extensive , critical illness and se- ton, IN, USA) by pushing coaxially the guidewire. vere ascites. While, the indications for replacement were After that, the needle is removed and the first small tube malfunction or dislodgment or request of the refer- caliber introducer is inserted to secure the tract; the an- ring physician or patient.4,5 chor bar is then retracted and first suture between ante- Approval to the procedure was obtained from the hos- rior abdominal and stomach wall has been completed as pital ethics committee and informed consent obtained the T-fastener mechanism is fixed externally by suture; from all patients. one or two T-fasteners are usually placed nearby the site of proposed gastrostomy entry.1,3 2. Procedure introduction Serial dilatation of percutaneous gastric tract is done The protocol was identical for all the patients on first with Seldinger technique using dilators up to 12-14 F: fi- placement or replacement: before the procedure, complete nally, gastrostomy polyurethane (Wills Oglesby; Wilson anamnesis is obtained and a pertinent physical examina- Cook Inc., Bloomington, IN, USA) tube 12 F is placed, tion assured the appropriateness of gastrostomy (absence and fixed by means of a loop.3 of abdominal , or cutaneous scars), and of gastro- The correct position is checked again by injecting con- stomy substitution. trast through the tube; the stomach is then decompressed All procedures have been monitored by analyzing in- for at least 12 hours following the procedure. T-fasteners dications, patients selection, duration of the procedures, will be removed within 5-10 days, under fluoroscopic and mortality. control. The presence of an anesthesiologist in the angiographic All patients have a 30-day post-procedure period of ob- room was required, and the vital parameters were servation by the same physician performing the proce- monitored. Technical success was accomplished when the dure.4 gastrostomy tube was effectively placed into the stomach, 4. Procedure for replacement and the correct function of the was achieved.6 The same technique by insertion, under local anaes- thesia, of the guidewire through the tube and then the 3. Procedure for first placement placement of the optimal feeding tube in the matur tract. Patients usually were admitted to the hospital for at Two controls after the procedure and 24 hours later as- least 12 hours before the procedure. No sedation was sure the best standard of quality. used and no antibiotic were routinely given. The liver and S46 Gut and Liver, Vol. 4, Suppl. 1, September 2010

5. Major complications 4) Tube migration and the buried bumper syn- drome Major complication were defined as those who prolong- ing the hospital stay, requiring an additional procedure or The buried bumper syndrome is defined as migration of transfusion.1,2 the PEG tube into the gastric wall and the subsequent epithelization of the ulcer site. Buried bumper syndrome 1) Aspiration often manifests months to years after PEG placement Aspiration resulting in pneumonitis or pneumonia is (median duration was 35 months after PEG placement) as one of the most frequently reported major complications abdominal pain; difficulty feeding or flushing the tube; of PEG placement. Aspiration can occur either during or and inability to advance, withdraw, or rotate the tube. after the PEG placement procedure. Periprocedure aspira- Treatment involves removing the tube (which may require tion of oropharyngeal contents occurs in 1% of patients upper endoscopy), allowing the tract to close while an al- undergoing PEG tube placement and carries a very high ternative method of feeding is established, and then plac- mortality. The level of sedation, frequency of suctioning, ing a new PRG tube in a different location. and degree of elevation of the head of the bed may all 5) Gastrocolocutaneous fistula contribute to aspiration risk. Postprocedure aspiration consists of either oropharyngeal contents or refluxed gas- Although colonic perforation during PEG placement is a tric contents and tube feedings. Although a frequently rare complication, there are possibilities of such compli- used justification for PEG placement is the prevention of cations. The transverse colon is apposed to the greater aspiration, this is not supported by the available evidence. curvature of the stomach and if the stomach is not well Furthermore, many patients have macroaspiration of insufflated during placement of the PEG tube, the colon gastric contents and tube feedings. Close monitoring of may not be completely displaced out of the field, thus gastric residual volumes and holding feedings when high leading to puncture by the gastrostomy tube. Patients residuals are encountered may limit aspiration. The pres- who do not manifest signs of obstruction or ence of an abnormal swallowing evaluation and reflux can be managed by tube removal. In most cases, the fis- places patients at significantly increased risk tula will close and a second gastrostomy can be for aspiration pneumonia within 1 month of PRG performed. If obstruction or peritonitis is present or the placement. fistula does not close despite PEG removal, operative takedown of the fistula is necessary. 2) Peritonitis 6) Wound infection and necrotizing fasciitis Peritonitis is a feared complication of PRG that often carries a high mortality rate. Peritonitis manifests as ab- These complications occur along a continuum, from dominal pain, fever, and leukocytosis. Causes of peri- simple peristomal infections to life-threatening necrotizing tonitis include removal or displacement of the tube prior fasciitis. Peristomal wound infection is fairly common, oc- to tract maturation, leakage from the PEG puncture site curring in 5-25% of cases in cohort studies. Antibiotic in the stomach, and perforation of another visceral organ. prophylaxis has been found to be a cost-effective strategy There are no guidelines for the management of peri- in this setting. Necrotizing fasciitis is a very rare compli- tonitis, but generally patients are treated with broad-spec- cation and the most aggressive type of PEG-related trum antibiotics. wound infection. Patients often present with progressive erythema and edema around the site, that then progresses 3) Hemorrhage to bullous lesions; septic shock can develop rapidly. During the procedure hemorrhage may be caused by Mortality is greater than 50% in these cases. puncture of gastric wall vessels. The most common cause 7) Inadvertent removal of PEG tube of hemorrhage post-PEG is due to the ulceration of the gastric mucosa underneath the internal bumper when ap- Maturation of the PEG tract can occur as early as 1 plied in very tight approximation to the mucosa. week after tube placement. Often maturation takes up to Esophageal trauma, gastric erosions, and unrelated peptic 3 weeks given that a majority of patients are severely ill, ulcer disease are less common etiologies of gastro- on , malnourished, and generally manifest intestinal bleeding after PRG. Post-PEG hemorrhage is poor wound healing. Agitated or delirious patients who managed similar to other episodes of upper gastro- inadvertently pull out their PRG tube often can be suc- intestinal bleeding. cessfully managed with nasogastric suction and PRG Perona F, et al: Percutaneous Radiologic Gastrostomy: A 12-Year Series S47

replacement. Anecdotally, the PEG tract closes in 24-48 2. Mortality hours when the patient is treated with bowel rest with or without nasogastric suction. Subsequent placement of a Only one patient (0.2%) with severe neurologic dis- PEG tube in a new site is often successful. Signs of peri- orders died because of acute cardiovascular event: there tonitis mandate treatment with antibiotics and a surgical were no signs of correlation with the procedure. consultation. If a PEG tube is inadvertently removed from 3. Complications a mature tract (＞3-4 weeks old), a Foley catheter can be inserted to maintain tract patency, but this should not be In our experience major complications were drastically attempted if the PEG tract is immature. reduced by careful and state of the art technique, place- ment in the sterile environment of the interventional 6. Minor complications suite and long experienced operators. Only seven (1.3%) Leakage is a common complaint and a major symptom major complications occurred: four duodenal lesions with that causes the patient, family, or caregiver to request a peritoneal leakage, two gastric bleedings and one gastric PEG tube change. Factors that predispose to leakage in- erosive lesion. Duodenal lesion were managed by retract- clude caustic agents (ascorbic acid) infused via the tube ing the tip of the catheter and by medical therapy. Gastric or used to clean the skin around the stoma (hydrogen bleedings were correlated to the tight sutures of the peroxide) as well as local fungal or bacterial skin T-fastener in one case and to small gastric varices: both infections. Leakage occurring due to tube failure may oc- have been successfully managed. The gastric lesion due to cur in as many as 25% of cases at 5 months, and gen- decubitus of the indwelling nasogastric tube healed by de- erally requires tube exchange. Leakage from the stoma compressing the stomach and by medical therapy as well. usually occurs as the stoma dilates over time. Blockage of Twenty-four (4.5%) minor complications were easily man- the tube is also a common problem seen in patients with aged: 9 abdominal pain, 5 fever, 7 gastroparesis and 3 long-term PEG placement. Silicone tubes had statistically tube ruptures, near the external luer lock system. significant higher rates of blockage that correlated with a 4. Follow-up higher rate of fungal colonization in the tubes. Tube blockage can be minimized by frequent water flushes after All patients underwent contrast examination the day af- feeding, only administering liquid medications or ter insertion. The median clinical follow-up was 4.4 well-ground pills via the tube, and avoidance of materials months (range, 1-10 months). likely to adhere to the inside of the tube. Blockages can Eleven short term malfunction (2%) which required to often be removed at bedside either by flushing the tube repeat the procedures into the 30-day period were de- with warm saline, infusing a phosphate-rich solution, or tected; the reason was due to clogged tubes or accidental gently passing an endoscope cleaning brush through the catheter dislodgement or rupture. All were completed by tube. simple tube exchange (usually for a major caliber tube, 16/18 F) under fluoroscopy, without complications. RESULTS DISCUSSION 1. Success rate

Success rate for PRG was 100% both at first placement The growing experience of the percutaneous method of- both at replacement, and enteral nutrition was started on fered to the clinicians a valuable alternative for nutrition the second day using nutripump with a specific nutri- support increasingly applied in patients in whom they tional protocol. In the 29 patients (5.4%) without an in- judged this method preferable to PEG, either in antici- dwelling nasogastric tube, the oesophagus was cathe- pation of failure of endoscopy or in order to avoid me- terized with a 5 F catheter in a median time of 3 minutes chanical disturbance of recent surgical flaps or grafts in (range, 1-12 minutes). The median time required for gas- the head and neck region by an endoscopic procedure. tropexy was 8 minutes (range, 5-12 minutes) and that for Percutaneous gastrostomy techniques with either radio- subsequent gastrostomy tube insertion was 9 minutes logical or endoscopic guidance have replaced surgical gas- (range, 6-14 minutes). The median total procedure time trostomies because of the risk of general anaesthesia and was 21 minutes (range, 18-37 minutes). the increased morbidity: in general, gastrostomy tubes al- Fluoroscopy levels were significantly monitored in order lows bolus feeding and are easier to place or replace.6 to reduce X-ray exposure and the average time was 2.1 This is a single-centre retrospective study designed to minutes (range, 1.3-9 minutes). evaluated the outcome of patients after PRG placement. S48 Gut and Liver, Vol. 4, Suppl. 1, September 2010

The outstanding benefit of the radiological technique is velliance the onset of such complications when comparing the fact that almost every stenosis of the hypopharynx or the 2 methods of PEG and PRG: in fact comparing the re- the oesophagus can be easily probed with hydrophilic sults obtained with 177 PEGs and 193 PRGs, Silas et al.13 guidewires and the respective catheters, which is the es- underlined indicated a major incidence of local infection sential precondition for the procedure. PRG represents affecting the radiologic method (23% vs 11%; p＜0.02). the technique of choice in amyotrophic lateral sclerosis Some authors report the a major complications rate for respiratory distress and lack of anhaestesia.7 ranging from 3-10% with PEG6 vs 0.5-6% with PRG.1,5,14 For fluoroscopic-guided gastrostomy, multiple gastro- Minor complications are rated on 6-33% with PEG vs stomy devices have been described in literature. The ini- 2.9-12% with PRG.8,9 In a further review, Giuliano et al.15 tially used Foley catheters have been demonstrated to in a series of 109 patients subjected to PRG by large cali- have an increased morbidity rate including tube leakage, ber tubes (20-24 F) found a rate of minor complications breakage, migration, proximal small around 5.5%. and gastric wall penetration. Most commonly, 10- to 14-F These results may be probably correlated to the sub- catheters with a Cope Loop retention device have been stantial differences in the techniques of inserting the reported in the literature and were used at our institu- feeding tubes, the choice of different tube diameters and tion.8 the use of an array of different anchoring systems as bal- We performed gastrostomy insertions with the use of loon, pig-tail or mushroom.16 We are deeply aware of the T-fastener because of the absence of procedure related importance of gastropexy to prevent the accidental in- deaths, tube extrusion into the peritoneal space: gastro- sertion of both the guide and the tube into the abdominal pexy devices stabilize the stomach during PRG, provide cavity,17 but it is necessary to enhance the possibility of added security against tract disruption in the first few cutaneous bedsore problems and the onset of local pain days following catheter placement, reduce risk of site and peristomal infection if the traction is so strong to hemorrhage, help to prevent leakage of ascites around a cause ischemic complications and if the T-fasteners are gastrostomy catheter and is simple to use.3,5,9 Such an- not removed within recommended times (maximum 14 chors have to be cut 5-10 days post-insertion in order to days).18 So it is clear that to reduce the onset of compli- avoid a foreign body reaction, inflammation, or damage to cations in the daily practice the technical approach, the the gastric mucosa. Peristomal leakages, skin infections, operative protocols and the level of experience acquired and persistent drainage after removal of the gastrostomy by the Interventional Group are the keypoints to achieve catheters have been attributed to retain T-fastener. a better performance. Tube obstruction and dislocation have been considered Based on our experience to date, PEG and PRG are not in connection with the shape of the devices used by alternatives but complementary: PEG is still simple and Willis and Oglesby.10 The use of devices with wider diam- easy to perform and should therefore be considered as a eters (18-20 F) with internal balloon anchoring systems valuable technique, particularly in neurologic pathologies. (already used for PEG) has considerably reduced these In general, the fluoroscopic-guided percutaneous gastro- complications.11 stomy technique shows the advantages of both ease and The overall incidence of complications after PEG place- speediness and the high technical success rate of the ra- ment reported in the available literature is in the range of diological approach with the beneficial possibility to ex- 8-30%, and allows to consider the most serious events re- change the gastrostomy tubes that were traditionally used quiring treatment occur in approximately 1-4% of cases. with endoscopic assistance. However PRG permits identi- This list resumes the most serious complications: perfo- fication in patients in whom the colon may lie anterior to ration, intra-abdominal hemorrhaging and peritonitis - oc- the stomach.9 cur in ＜0.5% of cases.5 One disadvantage may be the smaller caliber of the In PRG the infection of the entry site is considered the tube and consequently the greater risk of obstruction: most frequent “minor” complication. The high rate of this however, the first tube can easily replaced with one of complication (around 15%) is certainly the result of the greater caliber after 15 to 30 days. Another disadvantage poor clinical conditions of the patients, but we have to is the lack of possibility to study gastric internal wall. take into account the protocols of managing, inserting the In conclusion, percutaneous radiological access is tech- device and keeping aseptic the entry site. It is mandatory nically feasible in nearly all of those cases in whom an to avoid excessive pressure and, consequently, ischemia of endoscopic attempt is not possible, because of stenotic the T-fastener system and external fixation system, which tumor, or other conditions that prevent transillumination might cause the infection.12 We have to take under sur- of the abdominal wall. Perona F, et al: Percutaneous Radiologic Gastrostomy: A 12-Year Series S49

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